posterior tibial tendon insufficiency (ptti) - foot & ankle - orthobullets

5/15/2014 Posterior Tibial Tendon Insufficiency (PTTI) - Foot & Ankle - Orthobullets.com

http://www.orthobullets.com/foot-and-ankle/7020/posterior-tibial-tendon-insufficiency-ptti 1/5

Author: Deborah Allen Topic updated on 03/15/14 3:47pm

15Posterior Tibial Tendon Insufficiency (PTTI)

Introduction

Posterior tibial tendon insufficiency is the most commoncause of adult-acquired flatfoot deformityEpidemiology

demographicsmore common in womenoften presents in the sixth decade

risk factorsobesityolder athletesinflammatory disorders

Mechanismexact etiology is unknown, but is assumed to be multifactorial

20% report an acute injuryPathoanatomy

tendon degeneration occurs in the watershed region distal to the medial malleolusbegins as tenosynovitis and progresses to significant tendinosis with an incompetent, painfultendon that lacks excursion fixed bony deformities occur at later stages

Associated conditionsyoung males with mild pes planus may have one of the following conditions

seronegative spondyloarthropathyinflammatory arthropathy

Anatomy

Muscletibialis posterior

originates from posterior fibula, tibia, and interosseous membraneinnervated by posterior tibial nerve (L4-5)

Tendonposterior tibial tendon (PTT) lies posterior to the medial malleolus before dividing into 3 limbs

anterior limbinserts onto navicular tuberosity and first cuneiform

middle limbinserts onto second and third cuneiforms, cuboid, and metatarsals 2-5

posterior limbinserts on sustentaculum tali anteriorly

Blood supplybranches of the posterior tibial artery supply the tendon distallya watershed area of poor intrinsic blood supply exists between the navicular and distal medialmalleolus (2-6 cm proximal to navicular insertion)

BiomechanicsPTT lies in an axis posterior to the tibiotalar joint and medial to the axis of the subtalar joint

functions as a primary dynamic support for the archacts as a hindfoot invertoradducts and supinates the forefoot during stance phase of gaitacts as secondary plantar flexor of the ankle

major antagonist to PTT is peroneus brevis activation of PTT allows locking of the transverse tarsal joints creating a rigid lever arm for thetoe-off phase of gait

Classification

Deformity Physical exam Radiographs

Stage I Tenosynovitis (+) single-leg toe raise Normal

Foot & Ankle

Introduction

Top High-Yield Topics

Foot & Ankle Biomechanics

Motion & Muscles of the Foot

Foot Muscle Forces &Deformities

Layers of the Plantar Foot

Nerve of the Foot

Ligaments of the Ankle

Ligaments and Fascia of theFoot

Ankle Arthroscopy

Ankle Arthrodesis

Hallux Disorders

Hallux Valgus

DJD & Hallux Rigidus

Sesamoid Injuries of the Hallux

Turf Toe

Hallux varus

Lesser Toe Deformities

Claw Toe

Hammer Toe

Mallet Toe

Synovitis of 2nd MTP

MTP Dislocations

Bunionette Deformity

Freiberg's Disease

Tendon Injuries

Posterior Tibial TendonInsufficiency (PTTI)

Anterior Tibialis TendonRupture

Search Join now Login

Home QBank Cases Videos Posts Groups Colleagues Messages About Feedback

Trauma Spine Sports Pediatrics Recon Hand Foot&Ankle Pathology Basic Science Anatomy Approaches

Free member since Mar '14

2 trackers blockedat orthobullets.comBlocked 22,813 trackers!



Stage I Tenosynovitis

No deformity

(+) single-leg toe raise Normal

Stage IIA Flatfoot deformity

Flexible hindfoot

Normal forefoot

(-) single-leg heel raise

Mild sinus tarsi pain

Arch collapse deformity

Stage IIB Flatfoot deformity

Flexible hindfoot

Forefoot abduction ("too many

toes", >40% talonavicular

uncoverage)

Stage III Flatfoot deformity

Rigid forefoot abduction

Rigid hindfoot valgus


Severe sinus tarsi pain


Subtalar arthritis

Stage IV Flatfoot deformity

Rigid forefoot abduction

Rigid hindfoot valgus

Deltoid ligament compromise


Severe sinus tarsi pain

Ankle pain


Subtalar arthritis

Talar tilt in ankle mortise

Presentation

Symptomsmedial ankle/foot pain and weakness is seen earlyprogressive loss of archlateral ankle pain due to subfibular impingement is a late symptom

Physical examinspection & palpation

pes planuscollapse of the medial longitudinal arch

hindfoot valgus deformityflexible stage IIrigid stage III, IV

forefoot abduction (Stage IIB disease)"too many toes" sign >40% talonavicular uncoverage

tenderness just posterior to tip of medial malleolusoften associated with an equinus contracture

range of motionsingle-limb heel rise

unable to perform in stages II, III, and IVdetermine whether deformity is flexible or fixed

flexible deformities are passively correctable to a plantigrade foot (stage II)rigid deformities are not correctable (stages III and IV)

Imaging

Radiographsrecommended views

weight bearing AP and lateral foot ankle mortise

findingsAP foot

increased talonavicular uncoverageincreased talo-first metatarsal angle (Simmon angle)

seen in stages II-IVweight bearing lateral foot

increased talo-first metatarsal angle (Meary angle)angles >4 indicate pes planus seen in stages II-IV

decreased calcaneal pitchnormal angle is between 17-32indicates loss of arch height

decreased medial cuneiform-floor heightindicates loss of arch height

subtalar arthritis



subtalar arthritis seen in stages III and IV

ankle mortisetalar tilt due to deltoid insufficiency

seen in stage IVMRI

findingsvariable amounts of tendon degeneration and arthritic changes in the talonavicular,subtalar, and tibiotalar joints

Ultrasoundincreasing role in the evaluation of pathology within the PTT

Differential

Pes planus secondary to midfoot pathology (osteoarthritis or chronic Lisfranc injury)

treat with midfoot fusion and a realignment procedureincompetence of the spring ligament (primary static stabilizer of the talonavicular joint) in theabsence of PTT pathology

treat with adjunctive spring ligament reconstruction in addition to standard flatfootreconstruction

Treatment

Nonoperativeimmobilization in walking cast/boot for 3-4 months

indicationsfirst line of treatment in stage I disease

custom-molded in-shoe orthosis

indicationsstage I patients after a period of immobilizationstage II patients

techniquemedial heel lift and longitudinal arch support

medial forefoot post indicated if fixed forefoot varus is present

UCBL with medial posting ankle foot orthosis

indicationsstage II, III, and IV patients who are not operative candidates, are sedentary and lowdemand (age > 60-70)

techniqueAFO family of braces (Arizona, molded, articulating)

AFO found to be most effective want medial orthotic post to support valgus collapseArizona brace is a molded leather gauntlet that provides stability to thetibiotalar joint, hindfoot, and longitudinal arch

Operativetenosynovectomy

indicationsindicated in stage I disease if immobilization fails

FDL transfer, calcaneal osteotomy, TAL, +/- forefoot correction osteotomy, +/- springligament repair, +/- PTT debridement

indicationsstage II disease

contraindicationshypermobilityneuromuscular conditionssevere subtalar arthritisobesity (relative)age >60-70 (relative)

triple arthrodesis and TAL indications

stage III disease stage II disease with severe subtalar arthritis

triple arthrodesis and TAL + deltoid ligament reconstruction

indicationsstage IV disease with passively correctable ankle valgus

tibiotalocalcaneal arthrodesisindications



Next Question

indicationsstage IV disease with a rigid hindfoot, valgus angulation of the talus, and tibiotalarand subtalar arthritis

Surgical Techniques

FDL transferindications

FDL is synergistic with tibialis posterior and therefore transfer can augment function ofdeficient PT

techniqueinsert FDL into navicular near insertion of PTvs. FHL transfer

FHL is more complicated to mobilize and has not shown improved resultsin the midfoot, FHL runs under FDL

Calcaneal osteotomy

indicated to correct hindfoot valgus techniques include

medial displacement calcaneal osteotomy (MDCO) used in stage IIA (insignificant forefoot abduction)

Evans lateral column lengthening osteotomy used in stage IIB (significant forefoot abduction)may require additional MDCO to correct the deformityoverlengthening may be corrected by a first TMT fusion or medial cuneiformosteotomy

TAL or gastrocnemius recessionindicated for equinus contracture

Forefoot correction osteotomy indicated for fixed forefoot supination/varus (stage IIC)techniques

plantarflexion (dorsal opening-wedge) medial cuneiform (Cotton) osteotomy used with a stable medial column (navicular is colinear with first MT)corrects residual forefoot varus after hindfoot correction is made surgically

medial column fusion (isolated first TMT fusion, isolated navicular fusion, or combinedTMT and navicular fusions)

used with an unstable medial column (plantar sag at first TMT and/ornaviculocuneiform joint)

Spring ligament repairindicated with spring ligament rupture in some cases

PTT debridementmay also be required

Triple arthrodesis

triple arthrodesis includes calcaneocuboid, talonavicular, subtalar joints additional medial column stabilization may be required

Please Rate Educational Value! Average 4.0 of 28 Ratings

Qbank (15 Questions)

Question: 1 of 13

TAG

(OBQ11.222) A 54-year-old female has a painful flatfoot that has not improved with over 8 months of conservative managementwith orthotics. Preoperatively, she was unable to perform a single-heel rise and her hindfoot was passively correctable. Figures Aand B are radiographs of the affected left foot. She undergoes FDL tendon transfer to the navicular, medial slide calcanealosteotomy, and tendoachilles lengthening procedures. Following these procedures, the appearance of the foot is demonstrated inFigure C. What is the next most appropriate intraoperative procedure to be performed during her foot reconstruction? ReviewTopic

FIGURES: A B C

1. Dorsiflexion closing wedge medial cuneiform osteotomy

2. In-situ 1st-3rd tarsometatarsal joint arthrodesis

3. Plantarflexion opening wedge medial cuneiform osteotomy

4. Lateral column closing wedge shortening osteotomy

5. Subtalar arthrodesis



Triple Arthrodesis in patient with Stage 3B PTTD.

General - Treatment Consult - Posterior Tibial Tendon Insufficiency (PTTI)

This surgical video demonstrates a triple arthrodesis in patient with Stage 3B P...

9/7/2012

326 views

Medial Displacement Calcaneal Osteotomy

Foot & Ankle - Surgical Techniques - Posterior Tibial Tendon Insufficiency (PTTI)

This is an osteotomy of the calcaneus for a flatfoot deformity to correct the hi...

7/21/2012

1469 views

Medializing Calcaneal Osteotomy - Animation

Foot & Ankle - Surgical Techniques - Posterior Tibial Tendon Insufficiency (PTTI)

Animation shows a Medializing Calcaneal Osteotomy using an Arthrex Step Plate. T...

7/21/2012

462 views

Plantarflexion opening wedge medial cuneiform osteotomy for

correction of fixed forefoot varus associated with flatfoot deformity.

Hirose CB, Johnson JE

Foot Ankle Int. 2004 Aug;25(8):568-74. PMID: 15363379 (Link to Pubmed)

Foot & Ankle - Journal Club - Posterior Tibial Tendon Insufficiency (PTTI)

3/23/2014

8 responses

Nonoperative treatment of adult acquired flat foot with the Arizona

brace.

Augustin JF, Lin SS, Berberian WS, Johnson JE

Foot Ankle Clin. 2003 Sep;8(3):491-502. PMID: 14560901 (Link to Pubmed)


3/23/2014

0 responses

Stage I and II posterior tibial tendon dysfunction treated by a

structured nonoperative management protocol: an orthosis and

exercise program.

Alvarez RG, Marini A, Schmitt C, Saltzman CL

Foot Ankle Int. 2006 Jan;27(1):2-8. PMID: 16442022 (Link to Pubmed)


2/18/2014

43 responses

See More Videos

5. Subtalar arthrodesis

PREFERRED RESPONSE

Videos

Posts

Groups

Oral Boards: Posterior TIbial Tendon Insufficiency (PTTI)

General - Oral Boards Review

7/29/2011

0 responses

Evidence & References Show References

Topic Comments

Please login to add comment.

posterior tibial tendon insufficiency (ptti) - foot & ankle - orthobullets

Documents

posterior limbinserts

posterior tibial artery

axis posterior

posterior fibula

posterior tibial nerve

navicular tuberosity

cuneiformmiddle limbinserts

medial malleolus